Clinical characteristics and management of liver abscess in The Gambia, a resource-limited country

Abstract

Liver abscess is endemic in resource-limited countries such as The Gambia where access to advanced imaging techniques or modern treatment modalities is limited. Despite this, mortality in this cohort was low. Therefore antibiotic therapy combined with percutaneous abscess drainage remains a reasonable treatment strategy of liver abscess in resource-poor settings.

Background

Liver abscess (LA) is endemic in developing countries, especially in tropical countries such as the Gambia. Pyogenic liver abscess (PLA) and amoebic liver abscess (ALA) are common types of liver abscesses, although tubercular and fungal abscesses have also been reported [1]. There are limited data on the clinical characteristics, management, and outcome of liver abscesses in resource-limited countries such as the Gambia where advanced imaging techniques and modern treatment modalities are in short supply.

Main text

The study is a retrospective cross-sectional study that was conducted at the specialist liver clinic of the Edward Francis Small Teaching Hospital (EFSTH), Banjul from January 2020 to November 2023. Thirty-one patients with liver abscesses were seen. The data indicated that young males in The Gambia are more commonly affected than other sectors of the population. It also revealed that most patients present with clinical, laboratory, and radiological features consistent with late presentation. Despite this and the lack of diagnostic and material resources, the use of ultrasound assisted percutaneous needle aspiration combined with antibiotics in the management of liver abscesses remains effective and safe in The Gambia, a resource-limited country.

• a) Clinical characteristics

The demographics of our patients were consistent with previous studies [2,3,4]. There were 17 young males, making up 56.7% of patients evaluated and the median age of these patients was 34 (10–73). The study did not find an underlying disorder or risk factor in the majority of the patients 20 (66.6%). Alcohol use was found in only 6 (20%) patients. The reason for this could be due to the fact that ALA is the most common liver abscess found in developing countries and is mostly related to poor socioeconomic status, malnutrition, and/or alcohol consumption [5,6,7,8].

The most common symptoms at presentation were abdominal pain in 28 patients (93.3%), weight loss in 27 patients (90%), and fever in 27 patients (90%), and the most common sign was hepatomegaly (seen in 26 patients, 86.7%). Apart from weight loss, these findings are similar to other studies [4, 9, 10]. The median duration of symptoms in our study was 21 days. This was different from a study in India which had a median duration of 10 days [9] and United Kingdom (UK) 14 days [11]. The presence of weight loss at presentation and a longer median duration of symptoms suggest that 1) most of the patients may have had a delay in the community and thus present late and 2) the majority of the patients in this study may have had ALA which is commonly found in developing countries and is associated with poor nutritional status.

• b) Radiological findings

Computed tomography (CT) scan is the diagnostic modality of choice for liver abscess because of its high sensitivity and specificity [2]. However, it may be expensive and not easily accessible in resource-limited countries; thus, ultrasound was utilized in this study. Based on ultrasound findings, most of the patients (25 patients, 83.3%) in the study had a single abscess and the majority of them (26 patients, 86.7%) were localized to the right lobe of the liver. This is consistent with the findings of other studies [4, 9]. However, the median abscess size in our patients was bigger (10.6 cm) with the majority (20 patients, 66.7%) having giant liver abscesess (abscess size ≥ 10 cm). These results were in contrast with other studies, which found smaller abscesses at presentation [3, 9, 12].

• c) Laboratory investigations

Abnormal laboratory parameters involved in cases of liver abscess discussed in the literature include leucocytosis, anaemia, elevated acute phase reactants (erythrocyte sedimentation rate, C-reactive protein), and altered liver enzyme levels [3]. This study also found hypoalbuminaemia in most 18 (60%) patients with a median albumin level of 28.7 g/l (normal: 35–50 g/L). Despite the effect of giant liver abscess on liver function, the hypoalbuminaemia could also be related to the low socioeconomic status of these patients which could result in poor living conditions such as crowded homes, poor hygiene, drinking of contaminated water and eventually malnutrition. Previous studies found a link between poor socioeconomic status and development of liver abscess, especially amoebic liver abscess [2, 13]. Gene Xpert for tuberculosis from the aspirates of all those who had ultrasound-assisted percutaneous needle aspirates were negative. Stool microscopy also did not yield any ova or parasites in the patient cohort. The following pathogens were cultured from the liver abscess aspirates: Staphylococcus aureus, Escherichia coli, Klebsiella species, Pseudomonas aeruginosa, coliform species, and Streptococcus species.

• d) Treatment

Antibiotic therapy contributes a crucial role in the management of liver abscess. In this study, only 16.7% of patients (5/30) were exclusively treated with antibiotics (ciprofloxacillin or ceftriaxone and/or metronidazole). The majority of the patients had both ultrasound-assisted percutaneous needle aspiration and antibiotics (25 patients, 83.3%). This is different from developed countries where pigtail catheters are readily available and are used [3]. None of the patients had complications related to percutaneous needle aspiration. Percutaneous needle aspiration combined with antibiotics appears to be a safe, effective, and promising treatment for pyogenic liver abscess of 3–6 cm in size [10, 14, 15]. Other studies have also found percutaneous catheter drainage to be more effective than percutaneous needle aspiration [16]. None of the patients underwent surgical operations. Outcome of open surgical drainage is found to be worse when compared with percutaneous drainage [9].

• e) Patients outcomes

The total mortality in this study was 3.3% (1 patient). The rest of the patients recovered fully. The patient who died had multiple, bilobular, pyogenic liver abscesses due to Staphylococcus aureus infection. Studies have reported a mortality rate of 2.8% in Thailand [17] and 12.3% in UK [11]. Deaths within 2 years of follow-up for ALA was found to be 3.33% in Bangladesh [7] and in hospital mortality for PLA was 2.2% in South Korea [18]. In another study, there were no mortalities for ALA but the 30-day mortality for pyogenic liver abscess was 5.3% [12].

The presence of weight loss, a longer median duration of symptoms, hypoalbuminaemia and giant liver abscess (abscess size ≥ 10 cm) in the majority of patients at presentation suggest that most of the patients with liver abscess present late. The reasons for this could be related to 1) delay in the community as most patients visit herbalist as first point of contact before visiting health facilities 2) The lack of specialist services (e.g. trained personnel, imaging services) in the primary and secondary health facilities which can result in miss diagnosis of patients liver abscess and 3) delay in health facilities before referring to tertiary facility due to inadequate referral protocol and guideline. The findings in this study further suggest that in resource-limited countries where advanced imaging techniques and modern treatment modalities for liver abscess are limited or unavailable, ultrasound-assisted percutaneous needle aspiration combined with antibiotic treatment still remains effective and safe in the treatment of liver abscess.

Conclusion

This retrospective cohort study conducted in the Gambia, a low-resource country, found that liver abscess predominantly affects mostly males with clinical, laboratory, and radiological features consistent with late presentation. In spite of this and the lack of diagnostic and material resources, morbidity and mortality rates in this cohort were low. This suggests that the current strategy of antibiotic therapy combined with percutaneous abscess drainage is a reasonable treatment strategy for the management of liver abscess in resource-poor settings.